Endocrinology & Metabolic Syndrome Abera et al.

, Endocrinol Metab Syndr 2017, 6:1

DOI: 10.4172/2161-1017.1000260

Case Report OMICS International

A Late-onset of Sheehan’s Syndrome Presenting with Life-threatening

Hypoglycemia
Abera H*, Berhe T, Mezgebu T and Woldeyes E
Department of Internal Medicine, St. Paul’s Hospital, Millennium Medical College, Addis Ababa, Ethiopia
*Corresponding author: Hailu Abera, Department of Internal Medicine, St. Paul’s Hospital, Millennium Medical College, Addis Ababa, Ethiopia, Tel: + 251 112 76 35 36;
E-mail: [email protected]
Received date: January 28, 2017; Accepted date: February 10, 2017; Published date: February 15, 2017
Copyright: © 2017 Abera H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

We described a case of 40 year-old lady who presented with a 16 year history of generalized fatigue and
recurrent episodes of hypoglycemia. She had a complete clinical evaluation, endocrine studies, and a pituitary
magnetic resonance scans that revealed pan-hypopituitarism secondary to Sheehan’s syndrome. She was given
hormone replacement therapy, which led to a significant improvement in lethargy, anorexia, muscle weakness, and
episodes of hypoglycemia. This case shows the impact of delay in the diagnosis of an easily treatable medical
condition and its consequences, especially for the population of a developing country like Ethiopia.

Introduction of axillary hairs and only sparse pubic hairs. Examination of other
systems was unremarkable.
Sheehan’s syndrome has an insidious course with variable
presentations. The majority of cases remain undiagnosed for many Laboratory findings showed a white cell count 4,000/µl, hematocrit
years after delivery. Here, we present a case of Sheehan’s syndrome 27.6%, MCV 95 fl, normal liver and renal functions, urine specific
presenting with recurrent hypoglycemia where a delay in its diagnosis gravity 1.000, Na+ 110 mEq/L, K+ 4.35 mEq/L, random blood sugar 54
resulted in significant morbidity to the patient. mg/dl, total cholesterol 130 mg/dl and triglyceride 62 mg/dl. Brain
MRI with Gadolinium revealed empty sella tursica as shown in (Figure
1).
Case Presentation
A 40-year-old lady presented to our hospital on August 1st 2016
with generalized fatigue of 16 years and change in mentation of one
week duration. The history dates back to 16 years when she had had
her second child with cesarean section for twin pregnancy with breech
presentation after which she had in hospital profuse vaginal bleeding
for which she was transfused with 6 units of blood. After the delivery,
she had failed to lactate and remained amenorrheic since then and had
never had any gynecologic evaluation. She was complaining of
progressive generalized fatigability and decreased exercise capacity
since the time of delivery. She had also a history of repeated low blood
glucose measurements for the past eight years for which she was being
managed with intravenous dextrose infusion and advised to take
caloric diet at the nearest health center.
Since the last one year she had excessive daytime sleepiness,
spending most of the day in bed. She also noticed a progressive loss of Figure 1: Sagittal gadolinium-enhanced T1-weighted MRI shows an
axillary and pubic hair, polydipsia (5-6 liters/day), polyuria and empty sella (red circle).
constipation.
One week prior to her current presentation, she developed bizarre As the clinical manifestations related to the patient’s previous
behavior followed by loss of consciousness within two days. She was obstetric history suggested Sheehan’s syndrome, relevant and available
then taken to a clinic where her blood glucose level was 39 mg/dl, hormonal studies were done (Table 1). After all these tests were
given dextrose infusion and referred to our hospital. performed, the diagnosis of Sheehan’s syndrome was made.
She has no history of long standing, headache, blurring of vision or The patient was started on intravenous hydrocortisone on an
diplopia. She has no history of head trauma, surgery or irradiation. emergency basis as inpatient and subsequently Prednisolone and
levothyroxine. She became conscious, started ambulating;
On examination, she was confused with a Glasgow Coma Scale of
hypoglycemic episodes disappeared and discharged with significant
14/15, hypotensive with blood pressure 85/50 mmHg, pulse rate 62
improvement. She was strictly educated about her illness and need to
beats per minute and afebrile. She had facial puffiness. There was a loss
take both Prednisolone and levothyroxine therapy for the rest of her

Endocrinol Metab Syndr, an open access journal Volume 6 • Issue 1 • 1000260

ISSN:2161-1017
Citation: Abera H, Berhe T, Mezgebu T, Woldeyes E (2017) A Late-onset of Sheehan’s Syndrome Presenting with Life-threatening
Hypoglycemia. Endocrinol Metab Syndr 6: 260. doi:10.4172/2161-1017.1000260

Page 2 of 3

life. Desmopressin therapy was also intended, but not possible to find
in the country.

Laboratory findings at presentation

Plasma Hormone Patient’s measurements Reference

Luteinizing hormone (mUI/ml) 0.10 7.7 -58.5 (post menopause)

Follicle-stimulating hormone (mUI/ml) 0.16 25.8-134.8 (post menopause)

Adreno-cortico trophic hormone (ng/ml) <1.0 1.6 - 13.9

Prolactin (mg/ml) <0.05 4.79-23.3

Thyroid stimulating hormone (µIU/ml) 0.16 2.5-5

Plasma cortisol at 8 Am (μg /dl) 2.57 6.2-19.9

Total triiodothyronine (μg/dl) 0.44 0.92-2.33

Total thyroxine (μg/dl) 0.63 4.0-6.0

Estradiol (pg/ml) <5.0 5.0-54.7 (post menopause)

Progesterone (ng/ml) <0.03 0.1-0.8 (post menopause)

Table 1: Endocrine studies at presentation.

Discussion exposed to stressful situations like surgery or infection for many years
after her delivery, when she presents with adrenal crisis [9].
Sheehan’s syndrome is defined as a pituitary hormone deficiency
due to ischemic necrosis of the pituitary gland from massive Less commonly, Sheehan’s syndrome can present acutely with
postpartum uterine bleeding [1]. It is an uncommon sequel of hypovolemic shock, hypoglycemia, severe hyponatremia, diabetes
postpartum hemorrhage in developed nations. It was first described by insipidus or psychosis [10]. There are multiple mechanisms resulting in
Sheehan [1]. However, in developing countries, postpartum pituitary hyponatremia in these patients. Hypothyroidism and cortisol
infarction remains a common cause of hypopituitarism [2]. Although deficiency can cause decreased free-water clearance and subsequent
Sheehan’s syndrome can present with acute severe pan-hypopituitarism hyponatremia. In Sheehan’s syndrome, there will also be severe
in some patients, the majority of patients is recognized with a clinical inappropriate secretion of antidiuretic hormone, which can also cause
subtle partial pituitary deficiency and therefore their diagnosis and hyponatremia [11,12]. Potassium level in this syndrome is not affected,
treatments are delayed for many years [3]. The magnitude of Sheehan’s because adrenal production of aldosterone is independent of the
syndrome is not well known, presumably because of the great number pituitary gland [13]. The response to fluid restriction is not complete.
of patients are undiagnosed. It is a rarely encountered disorder in Therefore, treatment with hydrocortisone is important to bring the
developed countries due to a better obstetric care [2,3]. But its sodium levels to normal.
prevalence is estimated to be still higher in developing countries where The diagnosis of Sheehan’s syndrome is challenging. It is based on
many deliveries take place at home [2]. clinical features of hypopituitarism in a woman with a history of
The magnitude of Sheehan’s syndrome in Africa is unknown, but as massive postpartum bleeding. Various symptoms will occur for specific
observed from different case reports a significant number of the deficiencies of anterior pituitary hormones. Prolactin deficiency can
patients are young women. The major risk factors identified are home cause failure of lactation. Gonadotropin deficiency will often cause
delivery and lack of obstetric care. Typical clinical presentations are amenorrhea or genital hair loss. Corticotropin deficiency can result in
commonly seen, but typical manifestations, including neuropsychiatric generalized fatigue, weakness, hypoglycemia, or dizziness. Deficiency
or electrolyte abnormalities are also observed. The delay in onset of of growth hormone causes fatigue, decreased quality of life, and weight
overt disease can also be too long [4]. There are no nationwide data on loss. Symptoms of central hypothyroidism are clinically similar to
the duration of onset of Sheehan’s syndrome, but there are many case primary hypothyroidism, but patients with central hypothyroidism
reports on literature. In a study of 60 cases, the average time between have low T3 and T4 levels with normal or even inappropriately low
the postpartum hemorrhage and diagnosis of Sheehan’s syndrome was TSH levels. Diagnosis of panhypopituitarism is straightforward, but
13 years [5]. partial deficiencies are often difficult to elicit [14].

Failure to lactate is often a common initial complaint in patients A patient with panhypopituitarism will have low levels of pituitary
with Sheehan syndrome (6). Many of them also report amenorrhea hormones (prolactin, luteinizing hormone, corticotropin, and
after delivery [7]. The diagnosis of Sheehan’s syndrome is not made thyrotropin) as well as the target hormones (estrogen, progesterone,
until several years in certain cases, when the features of cortisol and thyroxin) [15].
hypopituitarism become apparent in a woman who had a postpartum
bleeding [8]. A woman with Sheehan’s syndrome with undiagnosed
hypopituitarism might be apparently asymptomatic until her body is

Endocrinol Metab Syndr, an open access journal Volume 6 • Issue 1 • 1000260

ISSN:2161-1017
Citation: Abera H, Berhe T, Mezgebu T, Woldeyes E (2017) A Late-onset of Sheehan’s Syndrome Presenting with Life-threatening
Hypoglycemia. Endocrinol Metab Syndr 6: 260. doi:10.4172/2161-1017.1000260

Page 3 of 3

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Pituitary imaging with either computed tomography or magnetic incidence of Sheehan’s syndrome after obstetric hemorrhage. Fertil Steril
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empty sella [16,17]. fatality rates. Bull World Health Organ 78: 593-602.
5. Gei-Guardia O, Soto-Herrera E, Gei-Brealey A, Chen-Ku CH (2010)
In the treatment of women with hypopituitarism one should replace Sheehan's Syndrome in Costa Rica: Clinical experience on 60 cases.
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Hydrocortisone is replaced first because thyroxine therapy can (2011) UK guidelines for the management of pituitary apoplexy. Clin
exacerbate glucocorticoid deficiency and can induce an adrenal crisis Endocrinol 74: 9-20.
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In our patient, there was a significant delay in reaching at the Inappropriate secretion of antidiuretic hormone in Sheehan’s syndrome: a
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agalactorrea, secondary amenorrhea and recurrent hypoglycemia 1330-1333.
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syndrome.

References
1. Sheehan HL (1937) Postpartum necrosis of the anterior pituitary. J Path
Bacteriol 45: 189-214.

Endocrinol Metab Syndr, an open access journal Volume 6 • Issue 1 • 1000260

ISSN:2161-1017